Deprescribing of nonstreoidal anti-inflammatory drugs (NSAIDs) in elderly with chronic pain- when less is more: Systematic review
Dr. Ravleen Nagi
Saveetha Dental College, Chennai
Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely due to the anti-inflammatory effects in multiple health conditions. The major concern is polypharmacy in elderly patients 65 years or above which places them at increased risk of adverse drug reactions and mortality. Chronic use of NSAIDs could increase the risk of gastrointestinal bleed injuries and acute kidney injuries. Deprescribing is defined as a planned and supervised process of dose reduction of medication to reduce the burden of polypharmacy in older individuals. Literature has revealed studies showing deprescribing strategies with several classes of medications with positive outcomes in elderly patients, however there is lack of strong evidence to deprescribe NSAIDs in elderly. This paper compiles studies from literature that discusses clinical implications of NSAIDs particularly in oral health care and factors favouring continuation and deprescribing of NSAIDs in elderly suffering from chronic pain.
Materials and Methods: The electronic retrieval systems and databases PubMed/MEDLINE, Scopus, and Web of knowledge from July 2011 till July 2021 were searched using the combination of keywords.
Results: Five studies were included which elucidated that deprescribing NSAIDs did not cause harm and it may be reasonable to reduce dose or stop NSAIDs when symptoms are under control however unclear role of deprescribing aspirin was observed in end of life especially for patients with high cardiovascular risk.
Conclusion: There is low level of evidence on deprescribing of NSAIDs and a systematic process of reviewing individual medications should be followed before decision of continuation or describing of a drug.
Outcome after palliative radiotherapy and chemotherapy in elderly cancer patients
Dr. Abhishek Chakravarty, Dr. Yamini Bachheti, Dr. Sweety Gupta, Dr. Deepa M. Joseph, Prof Dr. Manoj Gupta
All India Institute of Medical Sciences, Rishikesh
Introduction: GLOBOCAN estimates suggest that malignancy in geriatric population account for about 51% of all cancers. Management of elderly becomes challenging due to their co-morbidities, performance status and various psychosocial issues. Also, it may be overlooked at an early stage as the subtle signs and symptoms can often be confused with other comorbidities which are common in this age group. Palliative care plays an important role at this age due to its individualistic approach and symptom relief. Patients with poor performance status or multiple comorbidities are more often treated with a palliative intent.
Aim: To assess the clinical outcome after palliative chemotherapy and radiotherapy in geriatric cancer patients.
Materials and Methods: Single institutional retrospective study at Department of Radiation Oncology, AIIMS, Rishikesh. It included 106 patients, age 65 years and above who were treated with palliative chemotherapy and radiotherapy between 2018-2021.
Results: 106 elderly cancer patients were assessed during the period (M: F-1.9:1). Age ranged from 65-91(Mean 70 years). Most common age was 65-75 yrs (71 patients). All patients presented in advanced stages with 55 patients having metastatic disease. 57 out of 75 patients completed palliative RT and 18 defaulted. 10 patients received palliative chemotherapy or hormonal therapy and 4 received both palliative RT and chemotherapy. 90 patients were analysed at the end of the study. Median survival was 21 months.
Conclusion: Geriatric patients presented with advanced disease with majority being metastatic thus palliative care becomes utmost important and should be individualised depending upon their performance status, co-morbidities, age, disease burden, acute symptoms and emergencies.
Assessment of end-of-life care and quality of dying in a tertiary hospital
Dr. Amit Jain, Dr. S. Khanna
Dharamshila Narayana Superspeciality Hospital,Delhi
Introduction: Out of total deaths in hospitals, 45.7 % people die with Terminal illness, patients in EOL care still contributes to all therapeutic and diagnostic tests which have not shown any survival benefits.
Aim: To Assess the Quality of Dying at the EOL care in relation to Investigations, treatments and Symptom Management.
Methods: Study type retrospective Study From records of the patients admitted in Oncology Wards in DNSH, July 2021 to Dec 2021. Inclusion Criteria: • Patient who died in the above period after 48 hours of admission. • Patients Above 18 years. Exclusion Criteria: Patients who died in ICU, ER and CCUs. All Data related to treatment, Diagnostic Procedures, Investigations and interventions were assessed from the Medical and Nursing Records. Quality of dying relationship was established with interventions like Hygiene care, suctioning, oxygen delivery, Mobilisation and Vascular access and other Invasive procedures.
Results: 104 patients included, Routine Blood tests were done in 85 % of patients (89/104), Respiratory fatigue72%, urinary Incontinence 45%, Pain 60%, Fatigue and Asthenia 32%, Fever 65%, Vomiting and cough 62% were Symptoms reported. ICU Consultant was most referral sought.
Conclusions: Procedures like CT scan, HD and ICU shifting shows attitude towards over treatment. EOL discussion by Physicians were Lacking. Palliative Consultant referrals were done in less than 10 % of patients and mostly at last few Hours of life.
Inhaled morphine for breathing difficulty in cases of CKD
Dr Amit Jain, Dr S Khanna
Dharamshila Narayana Superspeciality Hospital, New Delhi
Background: Dyspnoea is a subjective feeling of sensation of breathlessness and is one of the most common complaint in palliative patient. Systemic Morphine has a potential role in alleviating dyspnoea but still not so proven role if given through inhalational route.
Aim: The aim of this investigation is to study clinically any improvement in breathlessness of the patient with CKD, in which systemic morphine cannot be given safely.
Methods: • 10 CKD patients with Dyspnoea are given 30 mg of Morphine diluted with 5 ml of normal saline through Ultra nebuliser. • The subjective effects were recorded on a VAS scale of 1 to 10, one being normal and 10 being extreme dyspnoeic. VAS was recorded before, after 5 minutes, 15 minutes, 30 min,60 min of nebulisation. Respiratory rate, spo2 and BP were also recorded. • Adverse effects were observed.
Results: VAS was significantly reduced in 7 out of 10 patients with no major adverse effects on Respiratory depression, sleepiness, nausea or vomiting were reported.
Conclusion: Nebulised route of morphine can be used to alleviate dyspnoea and in recent studies have been proved that opioid receptors are located in trachea and major bronchus, the main site of action of nebulised morphine and is devoid of any adverse effects.
Consultant rehabilitation physician Institute of Neurosciences Kolkata
Dr Sucheta Saha
Neurodegeneration with Brain Iron Accumulation (NBIA): A Rare and Unique Challenge in Neuro-Palliative Care
Introduction: Neurodegeneration with brain iron accumulation (NBIA) is a rare heterogeneous group of neurologic disorders characterised by abnormal accumulation of iron in the basal ganglia. It is a relentlessly progressive neurodegenerative disorder, without any cure. Neuro-palliation and rehabilitation can play important role in management of this rare disorder.
Case Description: An 18-year-old male patient presented to the Physical Medicine and Rehabilitation Out Patient Department of VMMC & Safdarjung Hospital with features of gradually increasing involuntary movement of neck, speech and swallowing difficulties. He was a diagnosed case of NBIA with characteristic ‘Eye of the Tiger’ appearance in MRI. Pharmacotherapy did not show any significant improvement. Injection Botulinum toxin was given for his cervical dystonia and he achieved remarkable improvement in the FahnMarsden dystonia scale scoring 2 weeks after the injection.
Conclusion: Only a handful of cases are reported from India, who received mostly symptomatic treatment. Medications like Baclofen, Trihexyphenidyl has shown some effect. Some cases are also treated with Deep Brain Stimulation without much improvement. In this case, the effect of Botulinum toxin was noticeable and it improved the quality of life of the patient in conjunction with supportive rehabilitation care. It can be used as an effective adjunct to the pharmacotherapy in this rare neurological disorder.
A Descriptive Observational Study To Assess Care Giver Satisfaction In Patients Attending Palliative Care OPD in SMS Hospital, Jaipur
Dr Ashwin Mathur/Devdutt Sharma, Dr Yogendra Singhal, Dr Gaurav Sharma, Dr Devdutt Sharma
SMS Hospital Jaipur
Introduction: Understanding the profile of end users is a key input for designing a service. This study is to evaluate the satisfaction of the patient/ care givers with respect to the treatment given, relief obtained, patient education and counselling provided those coming for follow up in OPD of Department of Palliative Medicine, SMS hospital, Jaipur
Methodology: %All patients/care givers attending a follow up session 15 days after registration (first visit), will be provided a 20 point questionnaire to be filled (FAMCARE QUESTIONAIRRE). This questionnaire will be analysed to assess their satisfaction with the services provided by the health care providers in the OPD.
Sample size: %Sample size is calculated at 95% confidence interval, assuming maximum variance and 50% satisfaction of services. At the relative error of 10% minimum sample size calculated is 400.
Conclusion\Results: This tool was found very useful to ascertain caregiver satisfaction with the services offered.
Keywords: Palliative Medicine, FAMCAREQuestionairre
Symptom profile and outcomes of advanced cancer patients referred for palliative care in an emergency department in tertiary care oncology centre – A descriptive observational study
Dr. Anshita Sharma, Dr. Kashish Vats, Dr. Dhanashri Kudal, Dr. Prarthna Jayaseelan, Dr. Jayita Deodhar
Tata Memorial Hospital
Introduction: Patients with advanced cancer present with distressing physical symptoms frequently to the emergency department (ED). Palliative care (PC) plays an important role in acute PC emergencies, to reduce symptom distress and improve patients quality of life.
Aim: The aim of this study was to determine the patient characteristics, reasons for referral, symptom profile, interventions, goals of care and outcomes of patients with advanced cancer in ED and referred for PC in a tertiary care cancer centre.
Methods: A retrospective, descriptive, cross-sectional analysis of medical records of first assessment of patients referred to PC in the ED over a -2month period was done. Demographic characteristics, diagnosis, presenting symptoms, performance status, management and intervention and outcomes were recorded. Data was analysed descriptively, and statistical analysis was done using SPSS v25.
Results: Of 349 patient first assessment records screened, 250 met the eligibility criteria. Most patients were females 133- (53.2%) and median age was 50 years. 151-(60%) patients were resided out of Mumbai and 99 -(39.6%) patients were local, of which 69 -(67.65%) were enrolled in homecare. The most frequent cancer diagnoses were lung (18.5%), gastrointestinal GI) (17.3%) and head and neck (HN). (15.4%). The most common presenting symptoms were pain (37%) and dyspnoea (30.7%). 56.8% patients had poor performance status. Goals of care were documented in 194 -(77%) patients. 27-(10.6%) of patients died in ED. 188 -(75 %) patients were called for outpatient review after the palliative care consultation in the ED.
Conclusion: Advanced cancer patients who attended ED were mainly females, with advanced lung, GI and HN cancers and hailed from outside Mumbai. Pain and dyspnoea were the most common presenting symptoms and the main goals of care were best supportive and end of life care.
Feasibility of subcutaneous administration of drugs in outpatient palliative care
Dr Pratima, Sumitra Choudhary, Dr Manisha Hemrajani, Dr Anjum Khan Joad
Bhagwan Mahaveer cancer Hospital and Research Centre, Jaipur
Drugs via subcutaneous route (s.c.) provide quick symptom relief. Sc route has been used in hospice and inpatient settings.
Aims: To evaluate the effectiveness, feasibility and acceptability of sc route for symptom relief.
Study design: Prospective interventional study in a Palliative Care OPD at a tertiary cancer center.
Methods: 25 cancer patients with distressing symptoms [Numerical Rating Scale (NRS) >6].
Exclusion criteria: Anasarca, fluid overload, skin infection, bleeding diathesis, hypotension. 24 gauge cannula was inserted s.c. at upper arm. Symptom severity on NRS (0-no pain, 10-worst pain) at baseline, 15 minutes, and 30 minutes after drug administration was recorded. Indication of s.c. route, drug and volume, patient feedback (pain in comparison to iv route), side effects were recorded.
Results: Drugs used were Tramadol (68% patients), Metoclopramide, Morphine, Xylocard (infusion), Haloperidol and Dexamethasone. NRS for pain and vomiting decreased by >70% in all patients at 30 minutes. No local side effects. 64% patients were highly satisfied with s.c route 8% patients were neutral. 60% patients felt no pain at injection site, 36% experienced less pain than I.V. 56% patients had difficult venous access.
NRS for Pain and vomiting, Mean (S.D)
|Baseline||After 15 min||After 30 min|
|Pain||6.47 (1.80)||3.56 (1.53)||1.69 (2.24)|
|Vomiting||7.0 (0.89)||3.33 (1.50)||0.5 (1.22)|
Conclusion: Subcutaneous drug administration is a feasible, safe, efficient method of rapid symptom relief in busy outpatient settings. Most patients opined that the sc route was not painful or less painful than intravenous route.
Life sustaining treatment in palliative care: What, who, when, why and how?
Mohamed Adnan Khan, Dr. Leena V. Gangolli
Sukoon Nilaya Palliative Care Centre
Introduction: Palliative care involves maintaining the best possible quality of life throughout the trajectory of illness in a life limiting condition, the question remains as to what, who, when, why and how Life Sustaining Treatment (LST) should be a part of the care plan for a patient. As Palliative care providers, planning, withholding or withdrawing LST is one of the greatest dilemmas faced in daily practice.
Aim: To understand LST in palliative care; to whom does it apply, when, and the resources that assist us in planning the same.
Methodology: Review of cases in a palliative care centre in Mumbai dealing with both cancer and non-cancer patients. Review of important legal rulings pertaining to the cause, review of literature on a few of the validated assessment scales/tools relevant in assisting decisions on LST.
Results: 31 inpatients were selected, they included both cancer and other life limiting conditions, out of which 9 patients required decisions regarding LST. Amongst them, 3 patients were transferred to higher centres on emergency basis, 1 was treated with higher antibiotics and advised withdrawal of oral chemotherapy, 1 patient was considered for palliative oral chemotherapy, 1 patient received resuscitation on the caregiver’s request, and the remaining required nutritional optimization.
Conclusion: Using LST wherever appropriate has given us the opportunity to maintain the best quality of life for all our patients with cancer and other life limiting conditions.
Evaluation of preferred place of death among terminally Ill cancer patients in a tertiary care hospital in India
Dr. Suhana Sulfiker, Prashant Sirohiya, Sushma Bhatnagar, Seema Mishra, Rakesh Garg, Nishkarsh Gupta, Vinod Kumar, Sachidanand Jee Bharathi
Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A IRCH, AIIMS, New Delhi
Introduction: Studies have been conducted world wide regarding the preferred place of death (PPOD) in terminally ill cancer patients. However, there is paucity in literature exploring the reasons for the same.
Aim: To evaluate the PPOD among terminally ill cancer patients and its reasons.
Methods: This is a questionnaire based cross sectional survey done in patients admitted in the palliative care unit in BRAIRCH AIIMS, New Delhi from October 2021 to January 2022. Eligible patients were selected based on inclusion and exclusion criteria and informed consent taken. The questionnaire comprised of demographic details and questions pertaining to preferred place of death and its reasons.
Results: Out of 81 patients participated, only 34(41.9%) patients had a preferred place of death. 21(61.8%) of them preferred home, while 11(32.4%) preferred palliative care ward and 2(5.8%) preferred nursing home. Among 21 patients preferring home, 11(52.3%) wanted peaceful death without intensive procedures, 9(42.8%) wanted care only by loved ones, 9(42.8%) were fed up with long hospital stays and 8(38%) did not want to financially overburden their families. Of 13 patients who preferred places other than home, 9(69%) wanted pain free death, 6(46%) feared lack of accessibility of medical care during emergencies and 5(38.4%) did not want to depend on family for selfcare. 8(9.9%) patients had discussed PPOD with their primary family care giver (PFCG) and 4 of the PFCGs agreed with the same.
Conclusion: About two-third of patients chose home as their PPOD. However, there are discrepancies regarding same between patient and PFCG. Treating physician should address this issue and encourage effective communication regarding PPOD between patient and PFCG.
A pilot study to test the feasibility of qpl for indian cancer patients attending their first consultation for radiation therapy and their primary family caregivers
Dr Shweta Chawak1, Dr Mahati Chittem2, Prof Phyllis Butow3, Dr Haryana Dhillon4
Indian Institute of Technology Hyderabad, 2Associate Professor, Indian Institute of Technology Hyderabad, India, 3Professor, Centre for Medical Psychology & Evidence-based Decision-making (CeMPED), University of Sydney, Australia, 4Associate Professor, Centre for Medical Psychology & Evidence-based Decision-making (CeMPED), University of Sydney, Australia”
Introduction: A fundamental way patients and primary family caregivers (PFC) can participate in medical consultations is by asking questions, enabling their information needs to be met. Question prompt lists (QPL) is a tool that encourage question-asking and improve triadic communication (i.e., patient, PFC, physician).
Aim: To test the feasibility of two separate QPL developed one for Indian cancer patients and other for their PFCs attending their first consultation for radiation therapy (RT).
Methods: Using a non-randomised controlled trial (NRCT), patient-PFC dyads were assigned to the intervention group (i.e., the QPL was administered to them; IG; n= 10) or control group (routine consultation without the QPL; CG; n=10). Both groups were administered questionnaires on state anxiety (pre- and post-intervention) and consultation satisfaction (post-intervention). The consultation for both groups was recorded and qualitative interviews were conducted in the follow-up to understand their experiences.
Results: The results of the current study detailed findings for: (i) communication outcomes, (ii) psychological outcomes, and (iii) communication experiences. Patients in the IG recognised the need for more information and revealed that the QPL helped them clear their thoughts regarding the treatment. PFCs in the IG reported the QPL was useful to address their questions directly to their physician. There were various feasibility issues (e.g., recruitment, interruptions during consultations, and high follow-up dropout rates) and possible solutions are provided in this paper.
Conclusion: The pilot study findings underscore the need for a QPL and recognise its benefits to Indian patients about to undergo RT and their PFCs.
Collusion in palliative care setting in a tertiary cancer hospital
Megha Sharma, Dr. Pooja Mongia, Dr. Pratima Agarwal, Dr. Arati Hota, Dr Anjum Khan Joad
Bhagwan Mahaveer Cancer Hospital and Research Centre
Introduction: Many families withhold information regarding disease progression and life expectancy from the patient. Collusion can have a significant impact on the patient and the family1,2. Literate patients visiting “Cancer” hospitals may be better informed.
Aims and Objectives: To study collusion in an Oncology palliative care OPD and analyse the reasons behind collusion,
Methodology: Study design: Prospective Observational study. Patient and caregivers were administered semi structured questionnaires regarding the diagnosis, stage and prognosis. Patients were asked about their understanding regarding the “New department” referral.Usage of emergency services were also documented
Result: 75 patients (and caregivers) were interviewed. 34.7% patients were unaware of the diagnosis. Of those who knew about cancer, 32% did not know the stage. 88% of caregivers had grasped “incurability”. Only 3.8% permitted the palliative department to break the news to the patient, despite counselling. Collusion was more with increasing age (P= 0.022) and illiteracy (P=.002). Reasons for collusion: “recovery plot”, creating a curative aura (experimental chemotherapy to maintain the facade) protecting the patient from shock. The number of unscheduled visits were not significantly different in the two groups(1, 2)
Conclusion: Collusion was associated with illiteracy, but was significant even in literate patients, attending a tertiary cancer hospital. The “family autonomy” model, the needs of patient, caregivers informs our communication strategy.
Clinical Implication: Collusion is likely to be much higher in unlettered patients seeking treatment in multi- specialty hospitals.When the social structure does not permit prognostication, health care workers bear the burden of “non- disclosure”.
1. Chaturvedi SK, Loiselle CG, Chandra PS. Communication with relatives and collusion in palliative care: a cross-cultural perspective. Indian J Palliat Care. 2009;15(1):2-9. doi:10.4103/0973-1075.53485
2. Beng KS. Collusion In Palliative Care. Malays Fam Physician. 2006;1(2-3):62-64. Published 2006 Aug 31.
Impact of COVID-19 on palliative care services at a tertiary care cancer research centre
Ruparna Khurana, Dr Sushma Bhatnagar
Professor and HOD, Department of Onco-Anaesthesia and Palliative Medicine, BRAIRCH, AIIMS, New Delhi
Introduction: During the first wave of COVID-19 crisis in India, striking a balance between adequate pain relief in advanced malignancy patients and avoiding hospitals due to fear of contracting the infection was the biggest challenge for patients as well as palliative care physicians. This study explored the clinical profile of patients visiting PCU during COVID affected last year. This can give important insights for preparedness; amidst the continuous evolution of virus.
Aim: To analyse the pattern and profile of patients seen during the Covid affected year (March – December 2020).
Methods: Retrospective analysis of palliative care services offered at our hospital during the first wave of covid 19 from March to December 2020.
Results: A total of 338 patients were admitted with 129 males and 209 females, out of these 7 patients were Covid positive. Most common reason for admission was management of severe pain including 195 patients and other symptom management 108 patients, 115 patients underwent palliative procedures including ascitic tapping in 51 patients, pleural tapping 14 patients, pigtail catheter insertion in 6 patients and ICD insertion 7 patients.
Conclusion: Despite the lockdown during the covid 19 pandemic the palliative care services were uninterrupted and provided essential services to patients who could manage to reach the hospital.
Anxiety, stress, and depression among nursing staff deputed on COVID-19 duties and those on routine duties across government hospitals in Delhi
Nileema Sharad Shingade, Dr. B.R.A. IRCH AIIMS NEW Delhi
Dr. Anil Kumar Asst Prof., Vaish College, Bhiwani Email: firstname.lastname@example.org
Subodh Kumar Research Scholar, Dept of Psychology, BHU, Varanasi Email: email@example.com “
Introduction: Medical staff is in direct contact with the patients and experience high work pressure especially during the COVID-19 pandemic. Direct contact with the patients could create some psychological problems in this group. Thus, the prevalence of such problems must be investigated. The present research aimed to study the level of stress, anxiety, and depression among the nursing staff deputed on COVID-19 duties and routine duties across Government hospitals in Delhi.
Material and Method: The Sample of the study population consisted of a total of 100 nursing staff; 50 deputed on COVID-19 duties and 50 on routine duties across Government hospitals in Delhi, India. The required data were collected using the electronic version of the Depression, Anxiety, Stress Scale (DASS) tool. Descriptive statistics, as well as inferential statistics (the Pearson correlation coefficient), were used to analyse the obtained data in SPSS.
Results: The mean age of the study participants was 36.51(SD=7.84) years. The mean values of stress, anxiety, and depression in study samples were 9.76(SD=7.69), 6.58(SD=6.62), and 6.53(SD=7.11) respectively. There was no significant difference between nurses who were on COVID or non-COVID duty in the prevalence of stress, anxiety, and depression. Also, there was no significant difference between female and male nurses in respect to the prevalence of stress, anxiety, and depression. Anxiety was statistically significant with stress at 0.01 level and depression was statistically significant with age at 0.05 level and statistically significant with stress and anxiety at 0.01 level.
Conclusion: This study revealed that the majority of the participants had a normal level of stress, anxiety, and depression. The nurses who were posted on COVID duty had a higher level of anxiety, stress, and depression as compared to the nurses who were posted on non-COVID duties. The female and male nurses had more or less the same level of stress but the prevalence of anxiety and depression was more in male nurses as compared to female nurses.
Characteristics, symptoms management and outcomes in COVID-19 patients referred to palliative care in a tertiary hospital: Retrospective observational study
Leong Yoke Yeng, Liew Kean Yew, Fakhriah Binti Abu Bakar
YY Leong1, MD, MRCP, Fakhriah bt Abu Bakar1, MBBS, MMED, KY Liew1, MBBS, MRCP, YC Siow2, MBBS, MRCP, RACP, Richard Lim BL3, MBBS, MRCP, RACP Moh/Malaysia
Introduction: The emergence of deadly COVID19 variants poses unique challenges with inevitable premature death due to scarcity of resources in countries such as Malaysia. It is imperative that palliative care is provided with a proactive approach to symptom recognition, assessment, management and escalation to address their symptoms.
AIM: To evaluate the characteristic profiles, prevalence of symptoms with its management and the assessment based on clinical efficacy and RASS (Richmond agitation sedation scale) among agitated COVID 19 patients.
Material and Method: Retrospective review to retrieve electronic medical records from period 1 June 2021 - 31 July 2021 of COVID 19 patients referred to palliative care team and data analysis using IBM SPSS v.26.
Results: 154 (75 males, 79 females) with mean age 67 (20-95) years of COVID 19 patients referred to palliative team. Common comorbidities seen were hypertension (66%), diabetes mellitus (46.4%) and dyslipidaemia (16.9%). 50% of them had acute kidney injury. Patients were referred in median days 7 (4-11) of COVID 19 illness and majority in category 4 and 5 (79.3%) with days of palliative care involvement was 4. Most prevalent symptoms were dyspnoea (73.4%), agitation (41.6%). Common medications at median dose used were CSCI fentanyl at 300 mcg/d, midazolam 10 mg/d, haloperidol 1 mg/d. Among agitated patients, 70.3% in RASS above +2 improved to RASS below -1 at 84.3% in the last encounter. 73.4% concluded complete effectiveness in overall symptom control.
Conclusion: Rapid deterioration in COVID 19 with effective medications in symptom control is crucially needed.
Challenges in setting up a non cancer palliative care centre during the covid pandemic (Mumbai/Maharashtra)
Sandhya Shamshankar Rajhans, Dr. Adnan Khan
Sukoon Nilaya Palliative Care Centre
Introduction: The Covid19 pandemic sabotaged all industries of the world. The healthcare industry witnessed major issues too but at the same time there arose a need to expand services, and setting up a palliative care centre in such difficult times came with its own challenges.
Aim: (1) Reasons for setting up of Non-Cancer Palliative care centre in Mumbai. (2) Recognising the hurdles in setting up the centre during the Covid pandemic. (3) To describe the strategies used to counter the hurdles coming across while establishing the centre.
Methodology: (1) Written Records and non-participation observation. (2) Data collection: Interview and questionnaire.
Results: The main reason for having a non-cancer palliative care centre is the huge requirement of palliative care in life limiting conditions other than cancer. We started IPD, OPD, teleconsulting services and proposed homecare services. Due to the Covid-19 pandemic and its restrictions a variety of social, financial, infrastructural, logistical, networking, clinical and non-clinical issues were encountered. Teleconsultations, online meetings and education, online transactions, mobilisation of resources as and when lockdowns were eased, PPE use and immunisation, RTPCR testing strategy, networking with other partners for referrals and assistance was done.
Conclusion: The palliative care centre was successfully started and continues to function. A wide spectrum of issues were encountered and addressed in the best possible way. But, as the pandemic continues, some challenges pertaining to OPDs, home visits and even IPD still exist.
Response of paediatric palliative care centre-subhita, during COVID-19 pandemic in Delhi NCR and North India
Dr. Shriya Raina, CanKids...
Dr. Sorabh Garg2 (Senior Palliative Care Physician, CanKids), Ms. Huma Anis3 (HOD, Paediatric Psycho-oncology programme, CanKids), Mr. Mukul Marwah4 (Vice-Chairman, CanKids), Dr. Haresh Gupta5 (HOD, Medical Support Services and Paediatric Palliative Care Programme), Ms. Poonam Bagai6 (Founder, Chairman; CanKids)
Introduction: During the lockdowns imposed in the pandemic, several children suffering from cancer faced difficulty in accessing care which led to disease progression or relapse for which certain measures needed to be taken to overcome these fatal effects.
Aim: Expanded role of Paediatric Palliative Care Centre in response to COVID to overcome the challenges for kids with cancer and families in Delhi-NCR and North India.
Material and Method: Increasing 10 beds at PPC and consolidating additional capacity at our “Home away from homes,” making total 50 beds for families stranded in lockdowns. Care coordination and shared care protocols with all 14 centres in Delhi-NCR and across Bihar & UP, specially for COVID designated hospitals was done. PPC provided drug support and delivery to families, patient transport services were organised, an EOL Afghan patient was sent by air. All care centres ran 24*7, doctors and nurses stepped up and 17 quarantines were managed by sharing facilities.
Results: Bed capacity was increased to 50 on which 901 families were supported, 864 patients were transferred to their respective hospitals within Delhi/NCR, 575 beneficiaries were provided psychological support, 1238 patients were supported via ambulatory clinic, 10 families were supported under shared care model, 2510mg of morphine was supplied to patients and 12 patients were provided end of life care.
Conclusion: A stand-alone PPC enables comprehensive and integrated paediatric palliative care services in a city or state specially in an emergency.
Managing Dental Anxiety in a Post COVID World
Dr. Deeptanshu Daga, Dr. Mohit Pal Singh, Dr. Apoorva Bhargava Daga
Pacific Dental College and Hospital
Introduction: The coronavirus pandemic has become a huge global challenge medically, economically and psychologically. Factors like disappointment, stress and irritability when in isolation are hypothesised to be one of the main mechanisms for dental anxiety. Dental anxiety, more specific and distressing than general anxiety.
Methodology: This study was undertaken to assess and counsel the dental anxiety and fear in patients visiting Pacific Dental College and Hospital. The patients were asked to fill the Dental Anxiety Scale Modified (DASR) questionnaire which was created in Google forms to avoid any form of contact. If the patient was unable to read or did not have smartphone capabilities the questionnaire was asked to patient while history taking and the responses were recorded. 544 responses were recorded. The patients were counselled acknowledging the patients concerns and working together to alleviate these concerns.
Results: DASR score of <9 indicates mild anxiety, 9-12 indicates moderate anxiety, 13-14 indicates high anxiety, 15-20 indicates severe anxiety. The mean score according to our study was 9 on DASR with a standard deviation of 3.66. The presence of mild grade anxiety can be seen bordering on the moderate side. Women were found to be more anxious than men. Behaviour modification and information, with practical advice reduced anxiety.
Conclusion: Anxiety assessment is essential for patient management to ensure quality of care. Anxiety unattended can cause a) avoidance of treatment, poor oral health and poor quality of life. b) Strained dentist patient relationship, improper dental treatment. c) Vasovagal syncope, tachycardia and panic attacks.
Awareness and perception of the speciality of ‘palliative medicine’ at a tertiary care oncological centre in India: A cross sectional observational study
Dr. Himanshu Prince, Dr. Indubala Maurya
Assistant Professor Department of Anaesthesiology KSSSCI Lucknow U.P.
Kalyan Singh Super Speciality Cancer Institute Lucknow
Introduction: Each year an estimated 40 million people are in need of palliative care, but lack of training and awareness on palliative care for health professionals is a limiting factor in delivering it. Current health care education focuses mostly on cure while palliative care including end-of-life care is compromised or non-existent. This study helps to understand adequacies in various aspects of palliative care knowledge among health care workers.
Aim: To appraise the level of awareness regarding different aspects of palliative medicine among doctors.
Methods: A cross sectional observational study was conducted using 22-point questionnaire via Google Forms through email. Total 75 working doctors (junior residents, senior residents and faculties) working at Kalyan Singh Super Speciality Cancer Institute Lucknow were the target population.
Results: Out of 75 doctors, 54 participated in the study. 37% (20) participants incorporated palliative care only for advance/terminal stage while 13% (07) did not have idea regarding incorporation of palliative care. 37% (20) never have been involved in palliative care of a terminally ill patient. 33.3% (18) participants never heard of hospice. According to 46.3% (25) participants they are not trained/oriented enough to deliver palliative care/terminal care to their patient.
Conclusions: The outcomes of the study showed that the awareness regarding palliative care among doctors even at a tertiary care oncological centre is inadequate. Majority of doctors uncertain in their approach of delivering palliative care.
Factors affecting palliative care needs in GI tumour patients
Dr. Amit Jain, Dr. S Khanna
Dharamshila Narayana Superspeciality Hospital, New Delhi
Background: GI tumour with a relatively longer life needs a long-term palliative care. Symptom management and Quality of Life takes predominance over the curative part.
Aim: Our study will focus how and what factors got affected and interfere with quality of life of patients with GI tumour.
Method: We designed a Questionnaire and was given to all GI tumour patients admitted in our hospital
Place of Study: DNSH, Delhi
Time Period: Jan 2021 to Dec 2022
Inclusion Criteria: • Patients with confirmed diagnosis of GI tumour. • Age above 18 years. • Admitted for Chemotherapy (Irrespective of First line or multiple lines) or supportive Care.
Questionnaire: Was designed with parameters as: • Physical (Pain, Constipation, Nausea, Breathlessness and loss of appetite). • Psychological (Depression, Anxiety and Sleep Disturbances). • Spiritual (acceptance).
Results: 56 Patients were admitted in the given period, out of which 48 filled the complete questionnaire: • It was found that Patients who are admitted for first chemotherapy have more of GI symptoms like diarrhoea, vomiting and more Fatigue, anxiety n Depression while patients on palliative chemotherapy and supportive care have less GI symptoms. • Educated Patients, Married ones have better understanding of disease and have better Quality of Life. • Females have more or less same symptoms but better quality of life.
Remarks: There is significant association of Palliative Care and Quality of life in GI tumour and is dependent on multiple factors.
Perceptions and knowledge gap in palliative care among undergraduate medical students in puducherry
Latha A, Tutor CON, AIIMS Jodhpur
Naresh Kumar Associate Professor Surgery AIIMS Mangalagiri
Introduction: Under the NPCDCS program of Government of India, capacity building on Palliative care has been included as a strategy under the package of services both at community and tertiary care facility levels. However, palliative care teaching is still not mandatory in undergraduate medical curriculum. Hence a medical graduate lacks knowledge and confidence in providing appropriate palliative care to needy patients. Understanding the existing level of knowledge and attitude among students in the care of such patients can facilitate planning a need based curriculum.
Aim: To study the perceptions and assess the knowledge among undergraduate medical students in a private medical college in Puducherry which had an inpatient Palliative care unit.
Methods: After ethical clearance, a semi-structured questionnaire was administered to 265 final year MBBS students. The questionnaire comprised of 16 knowledge questions and six attitude statements on purpose of palliative care, pain management, communication skills and team concept. The descriptive data were analysed using SPSS-23.
Results: Majority of students (97.3%) had heard about palliative care. Cancer (88.6%), AIDS (28.6%), Spinal trauma (11.6%), XDR TB (5.6%) and Coma (4.5%) were listed as diseases that need palliative care. About 43.4% mentioned improving quality of life as the purpose of palliative care. Less than 50% of students felt that palliative care is provided only to terminally ill patients. Unawareness about analgesic drugs prescribed in WHO Ladder (66%) and principles in Communication (71%) were observed. Nearly half (49.4%) of the students felt oral morphine causes addiction. Majority (83.4%) of the students opined that palliative care teaching can be included in their curriculum.
Conclusion: The findings stress the need for filling the knowledge gaps by incorporating palliative care education in undergraduate curriculum.
The untold story: Disenfranchised grief of a caregiver
Nayana D R
Dr. Reena Joy, Medical Officer, Karunashraya Bangalore Hospice Trust, Karunashraya Institute of Palliative Care Education and Research (KIPCER)
Introduction: Disenfranchised grief refers to a loss that’s not openly acknowledged, socially mourned or publicly supported. The effects of disfranchisement have the potential to interfere with individuals’ ability to fully process and resolve their grief. The aim of this paper is to present a case report on identifying effects of disenfranchised grief and facilitate the grieving process in a caregiver of a terminally ill cancer patient.
Case Description: Case records were retrospectively analysed to collect the data for this report. The subject was a 45-year-oldunmarried, male businessman, belonging to an urban background, in a 15-year relationship with his female partner who had metastatic breast cancer. His grief was unacknowledged by both of their families because the relationship was unapproved by the society and the normal social supports were unavailable for the caregiver. He had intense emotional reactions mainly anger, expressed lack of trust in the healthcare system, appeared distressed with appetite and sleep disturbances, was unable to utilise his usual sources of comfort, and experienced increased social isolation. He had undergone counselling sessions for about one month (n=4). After four sessions, he started to work on his coping by journaling, sought support from family and friends, and was able to provide practical support for the patient. He was unable to accept the terminal nature of the illness, continued to experience guilt and self-blame, opted for aggressive futile treatment, which ultimately adversely impacted the quality of end-of-life-care.
Discussion: Lack of acknowledgement and support for a caregiver can become a barrier in processing the grief and related emotions ultimately affecting the caregiver’s coping and wellbeing. This also hampers the caregiver’s ability to support the patient through their treatment. Providing non-judgmental support, validating the loss, identifying support systems, with provision of continued support may help in the management of disenfranchised grief and the related emotions.
Keywords: Grief in care givers; disenfranchised grief; terminally ill cancer patients;
Decision making in palliative care patients: Concordance between the clinical ethics and caregivers
Garima Rawat, Dr. Amit Jain
Dharamshila Narayana Superspeciality Hospital
Introduction: The World Health Organisation (WHO) defines palliative care as ‘an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual’. Ethics play an important role while providing care to the patients in need and providing this care is not possible without the support and understanding of family/care givers.
Aim: The aim is to review the presence of discordance or concordance in the between the principles of ethics and the expectations of the caregivers.
Methods: The published literature will be searched and reviewed to analyse the points of discordance or concordance considering all four cardinal ethical principles in regard to the care providers/care givers.
Conclusions: Eventually the patient is entitled to accept or refuse this treatment, according to his/her desires. Although, once the treatment is accepted, as long as s/he is aware of the incumbent process of dying, his/her would pursue his/ her desires reshapes the relations between ethics of practitioners and caregivers. The care providers are particularly hit by this change: they need both to support their loved one and to be supported in this final step.
Keywords: Palliative care; Ethics; Caregivers
Burden and coping mechanisms among caregivers of cancer patients: A cross sectional study
Damini Butola, Dr. Babita Prusty and Dr. Savita Butola
Amity University, Noida
Introduction: Caregivers play an important role in patient-care. Their well-being directly affects the quality of care. However, the caregiving burden can often negatively affect the caregivers’ own health and quality of life. Coping involves actions or thought processes, used in a stressful or unpleasant situation in order to modify one’s reaction to it. This can be through adaptive or maladaptive mechanisms which can further be problem-focussed, emotion-focussed or avoidant coping.
Aim: The aim of this study was to assess the correlation between the caregiver- burden and coping strategies adopted by cancer caregivers.
Methods: This was a correlational, cross-sectional study.The subjects were caregivers - persons who assisted individuals with at least one activity of daily living or instrumental activity of daily living (NAC/AARP 2004c), of cancer patients, (19-65 years), selected through purposive random sampling. Of the 91 responses, 81 matched the selection criteria. Data was collected online on caregiver burden and coping strategies using standard questionnaires.
Results: Pearson’s correlation was used to examine the correlation between caregiver burden and problem-focussed coping, emotion-focussed coping and avoidant coping. The least average burden was faced by caregivers above 50 years and that faced by those below 30 years and between 30-50 years was almost the same.
Conclusions: Problem-focussed coping was the most utilised coping strategy while avoidant coping was the least common. No statistically significant correlation was found between caregiver burden and the three coping strategies, in consonance with earlier studies.
Caregiver burden of COVID-19 patients admitted in a tertiary care hospital in north bihar during the severe second wave of the great pandemic in India
Burhanuddin Qayyumi - Assistant Professor, Head and Neck Cancer, HBCHRC Muzaffarpur, Dr Sanjay Kumar - Assistant Professor Psychiatry, SKMCH Muzaffarpur, Dr Bikash Kumar - Principal SKMCH, Muzaffarpur
Introduction: The severe second wave of SARS-COV-2 infections in India started in March 2021 and lasted for at least three months with peak cases surmounting more than 400 thousand per day. This unprecedented surge of infections caused a massive impact on the overall health and public service system of the country. With running out of supplies of medical grade oxygen to prescription of untested expensive therapeutic options, there was general distress in the entire country, including the vast rural expanse of the country. We intended to study the caregiver burden of the attendants of hospitalised COVID-19 patient during this period.
Material and Methods: We prospectively enrolled patients with clinical SARI or pneumonia having an RTPCR positive report. Patients’ primary caregivers were interviewed using the short version of the burden scale for family caregivers as it was brief and least time consuming. The socio-demographic information, disease related information and financial aspects were recorded in the case record forms. We analysed the descriptive statistics and correlation of the caregiver burden score with the various factors. This was done using SPSS version 26, IBM, New York. We also conducted a rapid antigen testing (RAT) of the primary caregiver to assess the rates of infectivity amongst the primary caregiver.
Results: A total of 50 patients were enrolled in the study. We compiled the socio-economic and demographic data. The overall positive correlation with burden scores more than 20 was interestingly associated with male family caregivers, migrant workers and with those with a monthly income < 5000 on multivariate analysis. Female caregivers - spouses or daughters, generally scored lower on the caregiver burden scale. Interestingly we found that rates of cross infection to the primary caregivers were only 18% on RAT at the time of interviewing. Moreover we reported the burden of arrangement of oxygen before and during the course of treatment adding majorly to caregiver burden.
Conclusion: The second wave of COVID-19 had created a unique crisis with significant caregiver burden in the rural masses. The burden reported in our study is result of the multifaceted problem of lack of equitable healthcare in the rural expanses of our country.
Symptom management and palliative treatment in paediatric cancer patients
Namitha R S
Nidhi Sharma Senior Resident AIIMS Rishikesh, Jyoti Singh Junior Resident AIIMS Rishikesh
Introduction: Childhood cancer is relatively rare. However, it is the 2nd leading cause of death among children. In developing countries rate of childhood cancer has increased in recent years and present at advanced stage as their symptoms are not detected early. Advanced disease leads to more physical discomfort and psychological side effects. Thus it is important to improve the patients and their families’ quality of life by providing palliative care.
Aim: To assess outcome after palliative chemotherapy and radiotherapy in paediatric cancer patients.
Method: Single institution cross sectional retrospective study conducted between July 2018 to 2021. Paediatric patients with various metastatic malignancies were included in the present study. Following parameters were assessed: Age, gender, tumour type, site, stage, treatment received and outcome.
Results: Total 25 paediatric patients with metastatic cancer were registered during this period. Most common type of cancer included Ewing sarcoma followed by Wilms tumour. Age ranged from 8 months-15 years. Out of 25 patients, 12 received palliative chemotherapy, 4 received palliative radiotherapy, 9 received both palliative chemotherapy and radiotherapy. Lung was the most common site of metastasis. Most common symptoms observed and managed in these patients were pain, breathlessness and spinal cord compression. At present 20 patients are alive and are on treatment.
Conclusion: Paediatric population are not diagnosed at any early stage as their symptoms are not identified early. However, in advanced malignancy, their quality of life can be improved by providing symptomatic treatment.
To study the clinical correlation between chemotherapy induced peripheral neuropathy (CIPN) with deficiency of Vitamin B12 and Vitamin D3
Dr Rabiya Abdu Razak Malayil, Dr Sushma Bhatnagar
AIIMS New Delhi
Background: The prevalence of CIPN has been estimated to be 68.1% in the 1st month after administration of platinum (oxaliplatin/carboplatin) or taxane based antineoplastic agents (paclitaxel/Docetaxel).The incidence of coasting phenomenon is seen in 60% of patients at the end of cancer treatment. These agents have increased the overall survival rate of cancer patients but with development of debilitating side effects like motor and sensory symptoms-numbness, paraesthesia,dysaesthesias,loss of balance,muscle weakness and burning pain which poses a great challenge for oncologists to warrant a reduction in the dosage or stop the chemotherapeutic course to mitigate CIPN symptoms. Therefore, it is of at most importance to develop prophylactic measures to prevent CIPN so that the patients can be cancer free and not suffer from debilitating neuropathy induced by cancer treatment.
Aim: Improvement in chemotherapy induced neuropathic pain symptoms on VAS scale and SLANSS scale through selective nutritional supplementation.
Materials and Methods: A total of 103 patients with clinically diagnosed CIPN were enrolled in the study. After taking informed written consent, all the patients had undergone a baseline workup of Vitamin B12 and Vitamin D3 levels. They were categorised into two groups – Deficient group and Non deficient group. Deficient group had been given Gabapentin and the deficient component (either Vitamin B12 or Vitamin D3 or both) whereas the Non deficient group received only Gabapentin as primary treatment. Both the groups were followed up at an interval of 3 months and 6 months with SLANSS and VAS scale for assessment of neuropathic pain.
Results: 103 patients were enrolled in this study- 49 cases of Ca Breast,35 cases of Ca Lung and 19 cases of Ca Ovary, they were followed up for a period of 6 months. Mean age was 43.94 years (range 28 to 68 years) consisting of 72 females and 31 males respectively. A comparative statistical analysis was done between Gabapentin treated cases and those with Gabapentin + Nutritional supplementation cases at 6 months. The S-LANSS pain score (10.57 v 5.24, P <.05) and visual analogue scale score (3.91 v 2.88, P <.05) showed a significant improvement between Gabapentin alone and Gabapentin+Vitamin B12 at 6 months follow up. Likewise, the S-LANSS pain score (10.57 v 6.7, P <.05) and visual analogue scale score (3.91 v 3, P <.05) showed a significant improvement between gabapentin alone and Gabapentin + Vitamin B12+Vitamin D3 cases at 6 months follow up.
Conclusion: The current data shows the treatment of CIPN using Gabapentin + Nutritional supplements shows significant improvement in reduction of pain as compared to Gabapentin alone cases at 6-month follow-up. Therefore, we can recommend the use of nutritional supplements along with Gabapentin to mitigate the CIPN symptoms in cancer patients.
Utilisation of intravenous lignocaine infusion as multimodal analgesic for chronic refractory cancer pain management
Dr Varun Shaileshbhai Yadav, Dr Ravi Umarania, Dr Bhavna Patel, Dr Priti Sanghvi
Gujarat Cancer Research Institute
Introduction: Patients with advanced cancer experience pain from progressive illness. Cancer pain is treated adhering to the WHO analgesic ladders. Some patients continue to suffer persistent pain and they are frequently unresponsive to escalating opioid doses. Lignocaine which is local anaesthetic with anti-nociceptive and anti-inflammatory property. Because of this property lignocaine appears promising approach in the management of chronic refractory cancer pain.
Aim: To evaluate the effects of intravenous lignocaine infusion on the chronic cancer pain and its short term efficacy and safety.
Material and Method: Prospective analytical study include 10 patients according to Inclusion and exclusion criteria. Patients enrolled in study received lignocaine infusion 4mg/kg in 100ml normal saline over 1 hour for consecutive 5 days. Pain intensity was assessed by VAS score and measured before and immediately after infusion. Vital are monitored and any side effects were noted. Patients were followed up after 2 and 4 weeks.
Result: Mean VAS score of 1st day before infusion is 7.9 (±0.73) which is reduced to 2(± 0.66) on 5th day and 3.1(±0.73) on 2nd week follow up. Also there were no need to increases dose of opioids. No major side effects were observed during or after infusion.
Conclusion: Intravenous infusion of lignocaine is effective for refractory chronic cancer pain without obvious side effects.
Novel intervention of low-dose menthol application for neuropathic pain: 308 case studies from a nepal hospital
Dr Ruth Powys, Ms Sunita Bhandari, Ms Purna Maya Thapa
Green Pastures Hospital
Background: Topical cold-induced analgesia with low-dose menthol for neuropathic pain (NP) is being explored internationally. Menthol selectively activates TRPM8 receptors in selected sensory neurones showing increased expression after nerve injury. Significant burdens of NP for spinal cord injury (SCI) and leprosy-affected patients (LAP) were previously highlighted in studies in Nepal: 51% (69/136) LAP had NP with moderate-severe impact on sleep (64%), mood (81%) and daily function (87%). Other international studies have shown similar results. NP in stroke patients is well recognised (41% central pain within first month).
Objective: To explore the effectiveness of topical menthol in mustard oil (alternatively sunflower oil) for NP in LAP, SCI and stroke.
Method: Case series using topical menthol 2 to 5% in mustard or sunflower oil applied to NP affected areas (& spine) twice daily for 6 weeks.
Data collected: 10-point Likert severity score; Brief Pain Inventory short form (BPISF); and Leeds Assessment Neuropathic Symptoms and Signs (LANSS) at baseline, 2-hour (2/24), 2-week (2/52) and 6-week (6/52) post-application.
Results: 308. pain episodes in 178 individuals (133 LAP; 34 SCI, 11 Stroke). Maximum severity score 10/10. ≥30% improvement from baseline: 2/24=18% (34/186); 2/52=91% (71/78); 6/52=82% (37/45); 2.9% (9/308) reported total relief. Total BPI (score 110) ≥30% improvement from baseline: 2/24=13% (24/186); 2/52=71% (55/78); 6/52=87% (39/45). LANSS (score 24) ≥30% improvement from baseline: 2/24=25% (46/186); 2/52=82% (64/78); 6/52=71% (32/45).
Conclusion: Topical menthol to treat NP in LAP, SCI and stroke leads to significant relief. Controlled trials to test effectiveness of this novel intervention are required to confirm these results and the number needed to treat.
Breathe with ease - palliation of dyspnea in interstitial lung disease
Dr. Dhanashri Kudal, Dr. Avinash Tiwari, Dr. Jayita Deodhar
Tata Memorial Hospital, Mumbai, Maharashtra
Background and Aim: Interstitial lung disease (ILD) is a rare chronic lung disease consisting of progressive fibrosis and scarring of lung parenchyma leading to dyspnoea, dry cough and ultimately, respiratory failure. Currently, the only approved drug for treatment of ILD with mild to moderate pulmonary fibrosis is pirfenidone. We hereby report a case of an advanced ovarian cancer patient with ILD in whom opioids and non-pharmacological management help in dyspnoea related to ILD by improving quality of life with decrease in O2 requirement.
Case Description: We present a case of 67 years old woman with recurrent ovarian carcinoma, with complaints of dyspnoea and dry cough, later diagnosed to be due to Interstitial lung disease. She had dyspnoea of grade MMRC-4, with a numerical rating score (NRS) of 10/10 and her SPO2 on room air was 88%. Chest auscultation revealed bilateral crepitations. She was treated with intravenous antibiotics, Pirfenidone, prednisolone and high flow O2 at 10L, but with no symptom improvement. She was started on oral Morphine 2.5mg q6hrly. We also started her on non-pharmacological measures of propped up position, pursed lip breathing, distraction and relaxation techniques, cool air over face and chest physiotherapy. After one week, she reported significant relief in severity of dyspnoea (3/10 on NRS) and reduction in O2 requirement to 2L. On her 2-month follow up, she needed lower dose of morphine and did not need any supplemental oxygen.
Conclusion: In this case, we observed that a comprehensive breathlessness management plan with low dose opioid and non-pharmacological measures improved dyspnoea and decreased hospital stay of a patient with ILD in an ovarian cancer patient.
How work related stress affects nurses in palliative care in Albania
Meksi Andia, Shkurti Enkelejda, University of Medicine, Tirana, Albania
Institute of Public Health, Tirana, Albania
Background: Understand work related stress that nurses in specialised palliative care services in Albania experience and what are some of the aspects that impact stress due to providing care for terminally ill patients.
Methodology: In order to get some insights on the experience of work related stress of palliative care nurses in Albania, we conducted 15 individual semi-structured interviews with palliative care nurses. The interviews were audio recorded and transcribed in verbatim and then analysed using the thematic analysis framework approach.
Results: 4 main themes generated from the interviews that were related to work stress of nurses in palliative care were: good team work, peer support and leadership, nurses who worked as a team, supported each- other professionally and personally compared to nurses who mainly worked alone and had less team work tasks. Also, nurses who felt that they were respected and taking good care of from the group leaders or service managers and that their emotional needs were met by them, said that they didn’t felt stressed. Creating a good relationship with the patient and their family members was considered very important to provide good home based palliative care. Patient and family compliance to treatment plan especially in home based palliative care context is an important factor on work satisfaction and performance from the nurses. Another, theme that came up from the interview was related to work expertise, nurses who had more work expertise were less likely to be stressed than the young ones.
Discussion: Despite the fact that the majority of the nurses felt that they didn’t experience high levels of or chronic stress due to their work, few of them mentioned some barriers that could affect indirectly to work related stress such as high work load, lack of transportation means and medical equipment, and lack of professional barriers.
Conclusions: Occupational and mental health care should be provided to nurses and other health professionals working in palliative care in order to enhance their awareness on work related stress and use of preventive strategies.
Pre-operative symptom burden among cancer patients– A prospective observational study
Nimish Singh, Dr. Mayank Gupta
All India Institute of Medical Sciences, Bathinda
Introduction: Cancer patients experience a multitude of symptoms which can negatively impact patients’ quality of life and function while increasing caregiver burden. One of the most critical aspects of symptom management is routine symptom assessment and reassessment—which allows symptoms to be recognised, diagnosed, treated and monitored over time. A knowledge of the types of symptoms affecting the patients and their effective management can go a long way in not only improving the outcome of patients but also in improving their quality of life. The present prospective study therefore aims at assessing the presence and severity of various symptoms in cancer patients presenting to the PAC clinic.
Aim: The aim of this study is to assess the presence and severity of various symptoms among the cancer patients presenting at the pre-Anaesthesia check-up clinic
Material and Method: Data from adult patients ≥ 18 years of age with known/suspected diagnosis of cancer and presenting to PAC clinic was collected. Self-report/caregiver/caregiver assisted assessment of symptoms using the “Edmonton Symptom Assessment Scale” (ESAS) was conducted at the time of the patient’s presentation to the PAC clinic by an independent physician or nurse unaware of the nature of the study.
Results: The average age of the patients was 51.9 years out of which 69.9% were females. Genitourinary cancers were the most common cancers among females. Forty six percent of patients had moderate to severe pain symptoms with a mean pain score of 3.6. The mean scores reported by patients for anxiety were also 3.6.The mean ESAS scores were highest in terms of wellbeing and restriction of movement being 4.38 each. Nausea and shortness of breath were the least important symptoms reported by the patients.
Conclusion: We found a very high symptom burden among cancer patients coming to the PAC clinic. This necessitates the routine assessment and management of symptoms in cancer patients presenting to PAC clinics.
Assessment of depression and anxiety in patients attending palliative medicine outdoor patient department
Dr Pratyasa Padhi, Dr Vinod Kumar
AIIMS, New Delhi
Introduction and Aims: The prevalence of depression in cancer patients ranges from 4.5% to 58%. Anxiety disorders have also been detected in cancer patients. Besides, there is often a high correlation between depression and anxiety in patients with cancer. Many patients with cancer experience mental health problems that represent clinically significant issues in their own right. Aim of the study is to assess prevalence of depression and anxiety in patients attending palliative medicine Outdoor Patient Department. The results can be used to understand the need of screening for depression and anxiety in patients of advanced cancers and address the relevant concerns in order to improve the quality of life of such patients.
Methods: Prospective observational study using Hospital Anxiety and Depression Scale-A(Anxiety), D(Depression) for assessment of depression and anxiety in patients attending palliative medicine OPD.
Results: Currently, the study is ongoing. 30 patients who came to palliative medicine OPD, were assessed using the HADS-A, HADS-D questionnaire. 8 patients were found to be cases of depression, 10 patients had borderline depression and 12 patients were normal. 5 patients had anxiety, 10 patients had borderline anxiety and 15 patients were normal.
Discussion and Conclusion: This study after completion shall give insight on prevalence of depression and anxiety in patients of receiving palliative care and shall assess the need of treating it. Depression being a significant determinant of quality of life, needs to treated in order to ensure a good quality of life in such patients.
Abbreviations: HADS- Hospital Anxiety Depression Scale, OPD- Outdoor Patient Department
Keywords: Depression, Anxiety, Palliative Medicine
Psychosocial suffering in palliative care: a review of two case studies
Dr. A. Latha, Dr. Srikanth Srinivasan
Background: Palliative care comprises a holistic approach in addressing the needs of patients. Sorting out psychosocial issues helps patients facing end of life situation to die with peace.
Methodology: The two case studies from a palliative care unit in Puducherry enlightens the comprehensive palliative care approach used by the palliative care team to manage the psychosocial concerns of end of life patients. Mr.X, a 70 years old married male, lived a comfortable life with two girl children. At one point of time, lost all his wealth due to family issues. His wife left him leaving behind him alone with two daughters. He went abroad to earn and did not return for more than 10 years and relatives with help of embassy they brought him back to India, got touch with first daughter,helped her married and lead a lonely life. In due course suffered from carcinoma lung with metastasis. When he was seriously ill, was brought to palliative care unit. His physical needs were sorted out. His psycho social concern was that he felt guilty for not done anything to second daughter and he was feeling guilty for what was happened in the past,wanted to ask sorry from his wife but he felt that was impossible. The palliative care team contacted his wife, apprised her the situation of Mr.X and requested her to come with the daughter and meet her husband. After continuous efforts, she came and talked with him. He was able to see and talk to his younger daughter and asked sorry from his wife after 30 years. He died on the third day after this meeting with satisfaction. Mrs X with hypopharynx cancer came to palliative care OPD asking for euthanasia. Her concern was in connection to her daughter’s two years of school dropout issue due to her cancer care. The palliative care team made arrangements for her daughter’s schooling she was on palliative tracheostomy. The patient died peacefully after two months of palliative care and later her daughter has completed her plus two education.
Conclusion: Relief of suffering is a central goal for palliative care. Achievement of this goal can be difficult if psychosocial concerns are not addressed.
Keywords: cancer, palliative care, psychosocial
Anxiety and depression in adult advanced cancer patients admitted in a respite palliative care unit
Dr. Tanvi Shinde
Tata Memorial Hospital
Introduction: Our hospital’s Respite Palliative Care Unit [RPCU] is the first of its kind in India where patients are admitted briefly for symptom control, psychosocial support, and empowerment of caregivers. This study focuses on presence and change in anxiety and depression in advanced cancer patients from admission to discharge.
Method: This study is a retrospective observational analysis of medical records of admitted patients for at least 7 days to RPCU from August 1 to October 30, 2021. Anxiety and depression have been measured by Generalised Anxiety Disorder 7 [GAD 7] and Patient Health Questionnaire 9 [PHQ 9] respectively at admission and discharge, according to standard care. Longitudinal change and influencing factors were determined using relevant statistical analyses.
Results: Of 57 patients admitted in the study period, 30 patients met the eligibility criteria. Majority were women (23, 76.6%) and the median age was 46 years. All patients had solid tumour, one had a haematological tumour. The median duration of admission was 9 days. On admission, anxiety was detected in 23 (76.6%) and depression in 26 (86.6%) patients. Moderate to severe anxiety was present in 16 (53.3%) patients on admission and 12 (40%) on discharge. 16 (53.3%) patients had moderate to severe depression on admission and 19 (63.3%) patients on discharge. There was a slight reduction in median score on GAD-7 (12 to 10) but no change in PHQ-9 score from admission to discharge (13). There was significant association between anxiety and depression with pain, breathlessness and fatigue, both at admission and discharge.
Conclusion: Anxiety and depression were present in 70-80% of advanced cancer patients admitted to RPCU which changed minimally at discharge. This highlights the importance of psychosocial assessment and need for intervention in RPCU.
A qualitative study to assess the quality of life of critically ill patients through home based palliative care
Dr. Manoj Kamal, Mamta Parihar, Hanife MacGamwell, Arvind Kumar Sharma, Ramswaroop Garva
Introduction: The aim of palliative care is to provide the quality of life not the quantity of life. It is specialised medical care for people living with a serious illness patient may receive medical care for their symptoms, along with treatment intended to cure their serious illness. The best place to live in the whole world is a home. A person feels most satisfied when he is at home with his family members. Which is even more prominent when a person has a life limiting illness. The quality of life effects immensely with the diagnosis of an incurable disease such as cancer.
Methodology: A total number of 28 registered patients with the diagnosis of cancer were visited at their homes for providing palliative care as a volunteering service. A phenomenological approach was used to assess their lived experience with cancer and their understanding about palliative care. 10 participants were also assessed for their satisfaction for the home care by the volunteer teams. The in-depth interviews were used for data collection. The participants responses were recorded and then translated into English language. Two of the participants were dead before the completion of the interviews. After decoding of the responses various themes and subthemes emerged.
Result: The result showed that almost all the participants major concerns were effective pain management, changes in physical and mental thought process, changed perspective towards life, depression, uncertainty about life and injustice by the supreme power. Participants also exhibit a higher rate of satisfaction with the services of palliative home care. A significant difference between the pre and post home visit was observed in addressing the total pain of the participants.
Conclusion: The study suggested that there is a certain trajectory of living pattern in patients with cancer and chronic diagnosis. The quality of life can be improved with the assistance of home-based palliative care to lessen the burden and anxiety of the patient, caregiver and the family. Furthermore, the study recommends that the implementation of policies and program to make home care available for patients confined to their homes can improve their perspective towards life.
Keywords: Quality of life, Palliative care, home care.
Relationship between so called “best possible care” and end of life care and quality of bereavement services in a cancer hospital
Dr. Amit Jain, Dr. S Khanna
Dharamshila Narayana Superspeciality Hospital, Delhi
Introduction: End of Life Care of patients is a complex process with a sole aim of reducing sufferings. It required a complex decision-making communication between the Physician, Nurses, patients and family members.
Aim: To study the Effectiveness of the EOLC and Care between Physicians, Patients and Family members and to assess Bereavement service.
Methods: Cross-sectional study in DNSH, Delhi. A Questionnaire was designed and was filled by Doctors, Nurses and Family members who were involved in EOL conversations.
Results: Of the 80 patients admitted for EOL in DNSH between July 21 to Oct21, it was found that Oncologists, who were directly in care of patients have communicated the patients n family members about the Prognosis but still continued For ICU shifting, Ventilatory requirement (if patient family wishes), Investigations and other Invasive Interventions like Haemodialysis as that all included in Best Possible Care available to them. Advanced Care Directives were taken by Intensivists in 10 % of patients when patients already been shifted there. Nurses have better EOL communication skills than Physicians. Bereavement Calls were never been made so far from ICU. Around in 15% of cases, Physicians received updates of funerals and other things on mobile as a message
Conclusions: Lack of communications skills in EOLC and bereavement policy to be developed effectively.
Occupational therapy in non-cancer palliative care: An uphill climb
Dr Sriharika Prakash, Mrs Jyoti Inamdar, Dr. Mohamed Adnan Khan
Sukoon Nilaya Palliative Care Centre
Introduction: There exists a myriad of non-cancerous conditions in palliative care that have a high symptom burden, a variable disease course and prognosis. It not only affects the patients, but also their families/ caregivers. In the holistic approach of palliative care, where every patient has a unique set of difficulties, a great challenge emerges in identifying and providing a patient centred and goal-oriented approach to attain an ideal quality of life in spite of the prognosis.
Aim: (1) To assess physical and functional limitations and provide various occupational, adaptive and adjunctive therapies to intervene, and thereby evaluate the results. (2)To describe the socioeconomic & architectural barriers that hinder adherence to rehabilitation.
Methodology: 28 patients and their caregivers from a single unit urban setup were identified. Paper based version of Functional Independence Measure and Functional Assessment Measure (FIMFAM) scale and a socioeconomic assessment by the medical social worker were used to evaluate.
Results: A significant improvement was noted in the FIMFAM scores of all the patients. The patients and caregivers had a better understanding of their physical and functional limitations. The FIMFAM scale and MSW assessment also proved beneficial in deciding interventions suited to their socioeconomic and vocational settings.
Conclusion: Occupational therapy involves scrutinising every factor pertaining to a patient and the family/caregiver including their socioeconomic and vocational settings. Once assessed in detail, the interventions significantly improve the patient’s quality of life, and also satisfactorily decrease the caregiver/family burden.
There is an end to cure but no end to care
Dr. Nidhi Adarshi
Pacific Dental College and Hospital, Udaipur, Rajasthan
Introduction: The goal of palliative care is to relieve the suffering of patients and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms experienced by patients. The importance of dental care is often overlooked due to the omission of the dentist as a member of the palliative care team. Many terminal patients exhibit oral difficulties that affect their quality of life. Palliative care dentists must exhibit empathy, compassion, and must be excellent communicators. Dentists can play an important role in alleviating both the physical and psychological pain of dying. This paper describes the role of oral physician in palliative care.
Aim: Prosthetic rehabilitation of surgically created defect in a patient with post operated cases of carcinoma.
Methods: Rehabilitation of surgically created defect using implant with fixed prosthesis.
Result: Permanent rehabilitation of defect was done using implant with fixed prosthesis.
Conclusion: A trained oral physician shall be a necessary team member for the oncologist or radiotherapist or other doctors of the palliative care team of head and neck malignancies for management of surgically created defect. By this paper we are trying to highlight on the role and need of an oral physician in palliative care practice.
Presented By: Dr Nidhi Adarshi, (PG IInd Year), Oral Medicine and Radiology, Pacific Dental College and Hospital, Debari, Udaipur, Rajasthan (India). nidhiadarshi3626@ firstname.lastname@example.org.
Division activities @ hospice - helping terminally ill patients to cope with their overall well-being in palliative care setup
Divya G, Michelle Normen
Karunashraya (Bangalore hospice trust)
Introduction: Patients dealing with advanced cancer are often challenged with problems related to their impending physical decline, changes in self and family relationships. In the hospice setting, the role of holistic palliative care delivery to relieve suffering can also be provided in the form of diversion therapy. Previous research evidence demonstrates that individuals with cancer who participate in the creative arts receive an opportunity to learn more about themselves, regain a sense of control, and develop stronger social bonds that can improve their overall well-being.
Aim: To understand patient experiences and coping after involving in diversion activities while in hospice care
Material and Method: We plan to conduct a qualitative study which will use a semi-structured interview schedule based on themes of healing, positive distraction, branding, de-institutionalisation, destressor and way finding (adapted from Miller MF & Kravits K,2013).
Results: The results of the proposed study will help us understand the benefits of diversion activities and the impact it has on patients’ experiences of their self and relationships while being in hospice care. The results will also help hospice care providers tailor-make diversion activities to suit individual needs better.
Conclusion: In conclusion, diversion activities in the form of music, creative art and crafts, board games and comedy shows which are organised for patients in hospice care can have positive benefits. The outcomes could be in the form of improved coping, reduction in distress, improved quality of interactions which would help them engage meaningfully when living with a life-limiting cancer.
Return to work after curative cancer therapy and the barriers associated with it
Dr. M.S. Biji, Dr. Praveen kumar Shenoy, Dr. Vinin N V, Sheeja Nellikka,Riyas, Dr. B. Satheesan
Malabar Cancer Centre
Introduction: Medical advancements and improvements in supportive care has resulted in better survival rates in cancer. However return to work(RTW) after completion of cancer treatment is a challenge and receives far too little attention among cancer survivors.
Aim: To study the proportion of individuals returning to work after completion of their cancer treatment and the barriers preventing them.
Methods: This was a prospective cross sectional study started in March 2021. Patients between 20- 65 years of age with employment prediagnosis and having completed atleast one year after their anticancer treatment were enrolled in the study after getting informed consent. Data collection was done through direct interview by investigator.
Results: A total of 114 survivors with mean age 50.4(range 25-61) years participated. Males constituted 79.8 %(N=91).Sixty two (54.4%) survivors belonged to the upper lower socio- economic status. Fifty one (45%) had early stage cancers(stage 1 and 2). with Head and neck primary (n=65,57%) being the commonest. Nearly 55%(N=63) of our survivors returned to work after completion of their treatment and mean satisfaction score among them was 7.6(range 3-10). Fifteen survivors (13%) had to change their occupation after cancer treatment. Among those who did not RTW, the reasons were physical barrier in 56%(N=29) followed by combined physical and psychological barriers in 21.5%(N=11). There were no other earning members in the family of almost 50% of the survivors.
Conclusions: The overall rate of RTW in our population was 55% which was comparable to other studies from Asia. Interventions directed at addressing the barriers interfering with RTW need to be formulated.
Ethics approval: No 1617/IRB-IEC/13/MCC/25-3-2021/4 Dated 8th April 2021
Holistic dentistry: Role in palliative care and spiritual healing
Dr. Kanchan Malawat, Dr. Jaya Mathur
Pacific Dental College
Palliative care is an approach that improves the quality of life of patient with life threatening illness and their families through disease specific treatment, symptom control and psycho- socio -spiritual care.
In similar manner, ‘Holistic Dentistry ‘ also known as ‘ Biologic Dentistry ‘, acknowledges and deals with the mind, spirit and body of the patients and not just their teeth.
Palliative care being multidisciplinary should include a dentist to treat patients exhibiting oral problems such as xerostomia, candidiasis, mucositis, poor oral hygiene, multiple caries, loss of masticatory functions, etc.
The above problems indirectly affect nutrition, emotional, social and spiritual wellbeing.
Who else can do it better than a holistic dentist who takes into consideration a person’s overall health while planning and evaluating dental health.
Healing itself is a miracle as how a process occurs to bring health, healing and wholeness back into injured person’s life.
It includes ‘ Great Chain of Being’-
Where spirit occupies the highest in the hierarchy.
Regarding the concept of Palliative care, there may be limits to cure, but care and comfort have no limits.
Its all about adding life to their days and not just days to their life.
Indwelling tunnelled catheters (ITC) for the management of malignant ascites and malignant pleural effusion: Experience in a tertiary cancer hospital in Indian scenario
Praneeth Suvvari, Abhijit Nair, Shyam Prasad Mantha
Basvatarakam Indo American Cancer Hospital & Research Institute, (BIACH & RI), Hyderabad
Introduction: Malignant Ascites (MA) poses significant symptom burden in patients with peritoneal malignancies at the end of life. Various treatment options are available and Indwelling Tunnelled Catheters (ITC) have the advantage of increased patient comfort being soft on abdomen, less painful, easy to tap fluid, and less chances of infection etc.
Methods: A total of 10 patients underwent insertion of ITC after proper counselling and assessment. 9 patients with MA and 1 patient with Malignant pleural effusion, underwent ITC placement Insertion was done in operation theatre under combined ultrasonogram and fluoroscopy guidance.
Results: 7 out of 10 patients had favourable outcomes in terms of symptom free days spent at home at end of life.
Conclusion: ITC’s are a suitable option to manage symptoms in patients with terminal malignant ascites. Careful patient selection and proper education of the caregivers will increase the success rates of procedures.
Synchronous pericardial effusion and superior venecava obstruction in a case of advanced neuroendocrine tumour of lung
Alice thankachan, Prof. Dr. Sushma Bhatnagar
Aiims, New Delhi
In the modern era of Medicine thoracic neoplasms and thrombosis induced by intravascular catheters account for the major cause of obstruction of superior venecava. Patients with ca lung, Non-Hodgkin’s lymphoma, mediastinal tumours and thymic neoplasms develops SVC obstruction during their disease course1 and it is associated with poor prognosis and a decreased overall survival2. Malignant pericardial effusion can be due to direct involvement of tumour itself or due to cancer directed therapies including chemotherapeutic drugs, radiotherapy3 and when it is associated with symptoms it may suggest an impending tamponade, an emergency which requires urgent surgical intervention. We report the case of an unusual presentation of neuroendocrine tumour of lung and SVCO with cardiac involvement. Echocardiography guided pericardiocentesis was performed in this case which presented with shortness of breath and features of right heart compromise. This case highlights the necessity of retaining a high end of clinical suspicion in such cases which if promptly identified can have important outcomes in the survival of patient. This reporting aims to alert the medical fraternity regarding simultaneous occurrence of two oncological emergencies having high mortality & morbidity.
The superior vena cava syndrome: clinical characteristics and evolving etiology.Rice TW, Rodriguez RM, Light RW,Medicine (Baltimore). 2006;85(1):37.
Prognostic Indicators of Outcome in Superior Vena Cava Obstruction in Lung Cancer,G. Rodrigues,K. Chu,International Journal of Radiation Oncology, Biology, Physics 69(3), S185,01-11-2007, DOI: 10.1016/j.ijrobp.2007.07.336
Richard I, Robinson B, Filice G, Miskoff J. Primary Lung Adenocarcinoma Presenting with Pericardial Tamponade in a Young Adult: A Rare Case Presentation. Cureus. 2020;12(1):e6827. Published 2020 Jan 31. doi:10.7759/ cureus.6827
Quality of life and symptom burden in patients with haematological malignancies receiving haematopoietic stem cell transplantation: A prospective observational study”
Neethu Susan Abraham, Dr Sushma Bhatnagar, Dr Seema Mishra (AIIMS, Delhi)
Background: Haematopoietic Stem Cell Transplant (HSCT) is one of the most intense form of treatment which can be threatening to life, but can give the hope to cure. The Quality of Life (QOL) has become a major end point for HSCT as over the years the long-term survival rate has improved. Prospective studies which provide valuable information on QOL is important to give the patients a better understanding of the endpoint further.
Aims: To assess the Quality Of Life and Symptom Burden of haematological malignancy patients at admission to hospital for HSCT, at 1 month and at 3 months following HSCT using FACT-BMT Scale and r-ESAS.
Methods: This prospective observational study was done on haematological malignancy patients who were admitted for HSCT in Dr. B.R.A IRCH, AIIMS. The study subjects were assessed by semi-structured socio demographic and clinical proforma & FACT-BMT Scale and r-ESAS at the time of hospital admission for transplantation, on day 30 (~1 month) & day100 (~3 months) of transplantation.
Results: A total of 68 patients were included in this study. A total of 8 patients expired during the study period and 1 patient was lost to follow up. The mean age of the sample was 42.92±14.78. There were 44(64.71%) males and 24(35.29%) females. Out of the 68 patients enrolled, the most patients were having multiple myeloma 48.53%(n=33), followed by Non Hodgkin lymphoma 22.02%(n=15). The FACT-BMT scores have decreased from baseline (F0) to first follow up (F1) and then increased in the third follow up (F2). The maximum ESAS mean score was for tiredness (2.13±2.03) among all other symptoms at the baseline (F0) as well as at 1 month (F1) (5.31±2.29) and at 3 months (F2) (1.27±1.98).
Conclusion: Symptom burden is the highest in the first month after BMT, which comes down later. QOL improves with time. It is very necessary to have assessment of symptom burden to provide good quality of life in such group of patients.
Keywords: Haematopoietic Stem Cell Transplant, Quality Of Life, Haematological malignancy.
Prevalence of anaemia in patients presenting to a palliative care unit of tertiary care center in india: A retrospective study
Bishnu Prasad Shrestha, Dr Sushma Bhatnagar
AIIMS, New Delhi
Introduction: Anaemia is a global public health problem and common clinical finding in cancer patients. The causes of anaemia are multifactorial. Anaemia causes fatigue, weakness, dizziness and shortness of breath; some of them might be so debilitating with adverse quality of life.
Aim: The aim of this study was to study the prevalence of anaemia in cancer patients presenting to palliative care unit.
Material and Method: This is a retrospective study done on 440 patients admitted in Palliative care ward over a period of 10 months in DR BRAIRCH, AIIMS, New Delhi, meeting eligibility criteria. Haemoglobin results were recorded and analysed in terms of various factors.
Results: Out of 440 patients, 234 were female. Based on World Health Organization criteria, anaemia was found in 88 % of men (Hb <13g/dL) and 72.6% of women (Hb <12 g/dL). Similarly, based on ICMR classification, 2 patients were having very severe anaemia (Hb<4g/dL), 48 patients were having severe anaemia (Hb 4-6.9g/dL), 60 patients were having moderate anaemia (Hb 7-9.9 g/dL) and 69 patients were having mild anaemia (Hb 10-10.9 g/dL).
Conclusion: Anaemia is highly prevalent in patients presenting to palliative care ward and is a major cause for symptom burden and poor quality of life. Management of anaemia in cancer patients is challenging and important as well. It is important to identify and treat anaemia right from the beginning to increase the efficacy of cancer treatment and improve the quality of life with potential decrease in frequency of hospital admission.
Use of indwelling peritoneal catheter for management of recurrent ascites in patient having terminal malignancy
Lekha Vijaykumar Raval, Dr. Ravikumar Umarania, Dr. Bhavna patel, Dr. Priti Sanghavi
Gujrat Cancer And Research Institute, Ahmedabad
Introduction: Patients with recurrent malignant ascites need repeated tapping with multiple needle punctures, frequent hospital visits which ultimately hamper the quality of life of patients and their caregivers.
Aim: Aim of this study was to assess effectiveness of Indwelling peritoneal catheter in symptoms control, its complications and improvement in the quality of life of patients and their care givers.
Material and Method: presented with the history of repeated therapeutic paracentesis and met with all inclusion criteria were selected for the procedure. They were evaluated for symptom relief(using Ascetic symptom inventory 7), complications and improvement in quality of life post procedure as weekly follow up.
Results: All 10 patients had successful catheter insertion with immediate relief in physical symptoms i.e. abdominal pain, fullness, fatigue, breathlessness, nausea, decreased appetite. ASI 7 score was reduced from 29.5(±3.1)to 13.9(±4.01) post procedure. No any immediate complications were noted. 20%,two patients presented with minor complications i.e., leakage from the site, local infection and Only 10%,one patient had systemic infection which responded to conservative treatment. No patient presented with major complications.
Conclusion: Indwelling peritoneal catheter is minimal invasive procedure, which can be safely used for recurrent malignant ascites for symptom relief and improvement in quality of life of patient and their caregivers.
Management of malignant ureteric obstruction with dexamethasone
Dr. Ishita Gandhi, Dr. Reena Sharma
Cansupport, A-2 Gulmohar Park, New Delhi
Introduction: Bilateral malignant ureteric obstruction occurs when a primary or metastatic malignancy in retroperitoneal area causes external compression and/or encasement of the ureters. Pharmacological methods or urinary diversion procedures are used for management.
Aim: A case report which shows symptoms due to bilateral malignant ureteral obstruction may be managed by pharmacological methods in palliative homecare.
Material and Method: An 85yrs female patient diagnosed with splenic lymphoma in 2015 on homeopathic treatment complained of severe swelling in lower limbs, decreased urine output, fatigue and constipation for 2-3 weeks. On examination, she had grade 3 oedema in lower limbs and Australian–modified Karnofsky’s performance score(AKPS) - 50. A recent CT scan showed both proximal ureters and right pelvi-ureteric junction inseparable from a mass caused by coalescence of retroperitoneal lymph nodes and mild to moderate bilateral hydronephrosis. A urinary diversion procedure was not possible for the patient. Renal function tests (KFT) showed mildly raised urea (62mg%) and creatinine (1.43mg%). The patient was started on oral dexamethasone 8mg which was given for 4 weeks halving the dose after the first week and again after the second week. She was also started on torsemide 5mg once daily initially till the swelling subsided.
Results: The patient showed a significant response within a week. After 2 weeks lower limb oedema decreased (grade 1), fatigue reduced and both activity and appetite improved. After 4 weeks, activity and appetite were almost normal. KFT also showed some improvement (Urea 58mg%, Creatinine 0.9mg%).
Conclusion: Dexamethasone is effective in relieving symptoms in patients with malignant ureteral obstruction.
Effective strategies to deal with chemical burn wound in an advanced cancer patient in respite palliative care setting – A case report
Dr. Akansha Chodankar, Dr. Jayita Deodhar
Tata Memorial Hospital
Introduction: Advanced cancer patient with malignant wounds experience multidimensional suffering which severely compromises comfort, dignity and quality of life. We herein report a rare presentation of patient with buccal mucosa cancer with a chemical burn wound which was managed in a respite palliative care setting.
Case presentation: A 36 years old gentleman with a diagnosis of buccal mucosa cancer on palliative chemotherapy was admitted to respite care facility for malignant wound myiasis management. The patient reported that this wound had occurred post dressing. On inspection and assessment, there was eschar over his upper back covering area up to bilateral mid scapular region and neck region measuring around 12 x10 cm and 6 x 6 cm respectively with seeping wound, blisters and very dark brown to blackish discolouration of skin. We considered a differential diagnosis of a chemical burn that caused extreme distress to patient and caregiver. Using specialist palliative care nursing approach, we applied Amnion dressing for chemical burn wound, followed by Karaya powder which helped in wound healing effectively.
Conclusion: Specialised wound care management is cardinally salient along with appropriate modification in wound dressing as per need.
Symptom palliation in metastatic carcinoma gall bladder patients: A retrospective report from a sub-himalayan high volume centre
Dr. Pragya Singh, Dr. Deepa Joseph, Dr Sagar N Raut, Dr Yanpothung Yanthan, Dr Shreyosi Mandal, Dr Sweety Gupta, Dr Manoj Gupta
All India Institute of Medical Sciences, Rishikesh
Introduction: Incidence of gall bladder cancer (GBC) is high in northern, eastern states (7–14/100,000 population) especially, Indo-gangetic plains compared to the south, western India (<1/100,000 population) with most being diagnosed at advanced stage and show poor prognosis, eligible only for palliative care.
Aim: To assesses the profile, treatment and outcome of metastatic GBC (mGBC).
Methods: Retrospective record analysis of mGBC patients registered and treated between January 2018-December 2019. Epidemiological profile, ECOG performance score (PS), metastatic sites, and treatment details obtained. Treatment compliance and overall survival were analysed.
Result: Out of 169 GBC patients, 62 histopathological proven cases were analysed. The mean age of presentation was 54 years, majority being females (69%) and maximum (87%) residing in Indo-gangetic region. 23% of cases were incidentally detected following cholecystectomy for suspected benign disease. 84% of the patients had good PS up to 2. Adenocarcinoma was identified in majority patients (63%) with liver metastasis in maximum (61%) followed by non -regional lymph nodes (35%), omentum (19.4%), lung (9.6%) and bone (3%) metastasis. 35% of cases presented with obstructive jaundice and 18 underwent PTBD and 3 biliary stenting. Only 29 (47%) patients received palliative chemotherapy (CT) mostly gemcitabine based, 4 patients were considered for best supportive care, and remaining 29 defaulted. 38% (11/29) of patients defaulted during first line of palliative CT. OS observed was 6 months (95% CI 4.7-7.2).
Conclusion: mGBC has a female preponderance with poor prognosis. Most of the patients belonged to Indo-gangetic region. The initial PS was good, but rapid progression and poor compliance to treatment resulted in low survival outcomes.
Assessment of quality of life in postoperative high grade glioma patientspost adjuvant CTRT
Shreyosi Mandal, Deepa Joseph, Ajay Krishnan,Pragya Singh, R. Lekshmi, Sweety Gupta, Manoj Gupta
Introduction: High Grade Gliomas (HGG), the commonest malignant tumours of the CNS, have a poor prognosis even with aggressive treatment which involves Surgery, Adjuvant Chemoradiotherapy followed by at least 6 months of adjuvant chemotherapy. Quality of Life (QOL)is influenced by the disease & the treatment.Due to the incurable nature of disease, palliation and the maintenance/improvement of the QOL is important in these patients.
Aim: Prospective study to assess the quality of life(QOL) in high grade glioma(HGG) patients post adjuvant chemoradiation.
Material and Method: 15 newly diagnosed post operative Grade III & IV gliomas prospectively enrolled & received adjuvant RT (60Gy/30 fractions) using IMRT with concurrent Temozolomide (TMZ) 75mg/m2 over 6 weeks followed by adjuvant TMZ 150-200 mg/m2. Pre-treatment QOL were assessed using Functional Assessment of Cancer Therapy-Brain questionnaire before start of RT and at 3 months post RT was done respectively.
Results: Median age was 45 years with a male preponderance. Commonest site was the parieto-temporal region.Right and left sided tumours were almost equally found.QOL improvement was noted indomains[PWB(p-0.2),SWB(p-0.2),EWB(p-0.6),FWB(p-0.7), BCS(p-0.6), TOI(p-0.5),FACT-G (p-0.6),Fact-Br(p-0.8).Values were not statistically significant.
Conclusion: QOL improvement was noted in the domains of Physical Well Being, Emotional Well Being, Functional Well Being, Brain Cancer Subscale, Trial Outcome Index & FACT-Br Total Score.Limitation of the study is the small sample size.Longer follow up is required to assess changes in the QOL brought about by CTRT.
Use of social media in palliative care setting to improve quality of life D
Logeswari1, A. Chandru1, S. Republica1, K. Gauthaman*1,2,3
*Corresponding author: email@example.com
1RMD Specialities Hospital and RMD Academy for Health (Unit of RMD Pain and Palliative Care Trust),T. Nagar, Chennai, Tamil Nadu, India 600017, 2Center for Transdisciplinary Research, Department of Pharmacology, Saveetha Dental College Hospital, Chennai, Tamil Nadu, India 600077, 3Research Director & Technical Advisor; Nibblen Life Sciences Pvt Ltd, Chennai, Tamil Nadu, India 600088
Introduction: The provision of specialised medical care for people suffering from serious illness, with the aim of relieving their pain and suffering and improving their quality of life (QOL) remain the bedrock of palliative care. Currently, the wide access to communication devices, internet connectivity and social media platforms have opened up a new interface in the field of health-care. We herein evaluated the utility and efficiency of the WhatsApp, a social media platform using a structured survey to bring the healthcare closer to hospice and home-care patients requiring palliative care and thereby improve their QOL.
Methods: We enrolled 120 male and female patients aged between (26 to 90 years) who were receiving palliative care therapy at RMD specialties hospital in the last 03 years. The patients and care-givers/family members were requestedto complete a structured questionnaire that comprised of fivequestionsprepared both in English and patient’s native language(Table 1). Thirty patients who completed the survey expressed their willingness for inclusion into RMD WhatsApp social media group and participate in the study. The group primarily consisted of the patient, their care giver/ immediate family member and the medical specialist.The well-being of the patient, the family support, the ease of communication, the time to availability of medical care and the overall effectiveness of the use of social media platform were analysed.
Results: The survey identified that 76.67% of the patients, care-givers and medical specialistsused WhatsApp social media platform (Figure 1A). Of these only 32.61% participated in the RMD Palliative Care WhatsApp group (Figure 1B). The patients showed maximal response (75%) in using the social media group, followed by family members (12.5%), medical specialists (7.5%) and care givers (5.0%) (Figure 1C). 98% of the patients who participated in the survey reported that the palliative care WhatsApp group was very useful while 2% mentioned that direct visits bring more emotional care and support (Figure D).
Discussions and Conclusions: The use of social media helped considerably in(a) reducing treatment costs by limiting the hospital visits;(b) educating the family members in caring and sharing the patient’s pain and suffering; (c) establishing a social community of palliative care patients to communicate and share individual experiences; (d) reducing patient’s anxiety and increasing comfort levels and (e) saving the quality time of the clinicians who can devote their precious time to attend to other immediate patient needs. In conclusion, our use of RMD Palliative Care WhatsApp group serve as an effective and useful tool to connectwith patients, provide timely care and improve their QOL.
Keywords: Palliative care; Care-givers; WhatsApp Social media platform; Survey; Quality of Life
Acknowledgements: The authors acknowledge the staff of RMD specialities Hospital, the family members and most importantly the patients who participated in this study.
|RMD Specialties Hospital and RMD Academy for Health (A Unit of RMD Pain and Palliative Care Trust) T. Nagar, Chennai, Tamil Nadu India 600017|
|No||Palliative care WhatsApp group – Questionnaire for patients/family members||Yes||No||Remarks|
|1||Were you able to get in touch with doctors/care givers easily and share your problems/needs?||√|
|2||Were you able to share/express your problems/needs freely and did you get the needed results/responses?||√|
|3||Did the use of ‘Palliative Care WhatsApp group’ help save cost?||√||Limited hospital visits|
|4||Did you face any problems in using the ‘Palliative Care WhatsApp group’?||√|
|5||Are you satisfied? If Yes, Will you recommend using the ‘Palliative Care WhatsApp group’ to other patients?||√||Very useful|
Effectiveness of aiims end of life care (EOLC) policy:- An observational study
Dr. Sarvadarshi Saraswata Mahapatra
AIIMS New Delhi
Context: Dying with dignity is the legal right of every humankind and breaking bad news must be the confidence of every treating physician dealing with life limiting illnesses. According to a study in 2015, India stood in 67th position amongst 80 countries in providing “good death”. Hence, AIIMS New Delhi has created a well-defined End Of Life Care (EOLC) policy to help patient suffering from life threatening illnesses to curtail unwanted medical interventions as well as to provide better quality of care staying within the boundary of ethical limitations with patient and his family’s consensus.
Aim: To evaluate effectiveness of AIIMS EOLC policy in real clinical practice.
Method: Data were collected from NCI, Jhajjar and IRCH AIIMS New Delhi,from November 2021 to January 2022.Response of patient/family regarding further management was recorded in terms of 1. Opted for home-based EOLC, 2. Hospital-based EOLC, 3. EOLC failure (prognostication insufficiency).
Result: A total of 32 cases were studied. Patient and care giver were counselled regarding EOLC and expectations. Of the 32 cases, 30(94%) cases were convinced well, whereas prognostication failures occurred in 2 cases (6%). Amongst 30 terminally ill patients,24(75%) patients went for home based EOLC, 2(<1%) patients opted for hospice care and 4(13%) patients stayed and peaceful death was offered to them.
Conclusion: AIIMS EOLC policy has successfully managed to handle deadly situations associated with life threatening illnesses, respecting care givers’ emotional involvements, has also contributed to reduce the hospital mis-hapenings tremendously.